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entitled 'Medicare Preventive Services: Most Beneficiaries Receive Some
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Testimony:
Before the Subcommittee on Health, Committee on Energy and Commerce,
House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery Expected at 2:00 p.m. EDT:
Tuesday, Sept. 21, 2004:
Medicare Preventive Services:
Most Beneficiaries Receive Some but Not All Recommended Services:
Statement of Janet Heinrich:
Director, Health Care--Public Health Issues:
GAO-04-1004T:
GAO Highlights:
Highlights of GAO-04-1004T, a testimony before the Subcommittee on
Health, Committee on Energy and Commerce, House of Representatives
Why GAO Did This Study:
Preventive care depends on identifying health risks and on taking
steps to control these risks. In contrast, Medicare, the federal
health program insuring almost 35 million beneficiaries age 65 or
older, was established largely to help pay beneficiaries’ health care
costs when they became ill or injured. Congress has broadened Medicare
coverage over time to include specific preventive services, such as
flu shots and certain cancer-screening tests, and the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
added coverage for several preventive services, including a one-time
preventive care examination for new enrollees, which will start in
2005.
GAO’s work, done before MMA, included analyzing data from four
national health surveys to examine the extent to which Medicare
beneficiaries received preventive services through physician visits.
GAO also interviewed officials from the Centers for Medicare &
Medicaid Services (CMS) and other experts and reviewed the results of
past demonstrations and studies to assess expected benefits and limits
of different delivery options for preventive care, including a one-
time preventive care examination.
What GAO Found:
Most Medicare beneficiaries receive some but not all recommended
preventive services. Our analysis of year 2000 data shows that nearly
9 in 10 Medicare beneficiaries visited a physician at least once that
year; beneficiaries made, on average, six visits or more within the
year. Still, many did not receive recommended preventive services,
such as flu or pneumonia vaccinations. Moreover, many are apparently
unaware that they may have conditions, such as high cholesterol, that
preventive services are meant to detect. In one 1999–2000 nationally
representative survey where people were physically examined and asked
a series of questions, nearly one-third of people age 65 or older whom
the survey found to have high cholesterol measurements said they had
not before been told by a physician or other health professional that
they had high cholesterol. Projected nationally, this percentage
translates into about 2.1 million people who may have had high
cholesterol without knowing it.
Estimated Number of Medicare Beneficiaries Age 65 or Older Who Were
Aware or Unaware That They Might Have High Blood Pressure or High
Cholesterol, 1999–2000:
[See PDF for image]
[End of figure]
A one-time preventive care examination may help orient new
beneficiaries to Medicare and provide further opportunity for
beneficiaries to receive some preventive services. Covering a one-time
preventive care examination does not ensure, however, that
beneficiaries will receive the recommended preventive services they
need over the long term or consistently improve health or lower costs.
CMS is exploring an alternative that would provide beneficiaries with
systematic health risk assessments by means other than visits to
physicians. A key component of this early effort involves the coupling
of risk assessments with follow-up interventions, such as referrals.
www.gao.gov/cgi-bin/getrpt?GAO-04-1004T.
To view the full product, including the scope and methodology, click
on the link above. For more information, contact Janet Heinrich on 202-
512-7119.
[End of section]
Mr. Chairman and Members of the Subcommittee:
I am pleased to be here today as you discuss seniors' health and the
preventive care benefits in the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (MMA). Overall preventive
care depends heavily on identifying health risks associated with the
onset or progression of disease and on taking steps to reduce or
mitigate these risks. The Medicare program, in contrast, was
established largely to help pay beneficiaries' health care costs when
they became ill or injured. Over time, however, Congress has broadened
Medicare coverage to include specific preventive services, such as
immunizations for influenza and pneumonia and screening tests for
certain cancers, that aim to keep an illness or condition from
developing or becoming more serious. Most recently, in passing the MMA,
Congress added coverage, to start in 2005, for a one-time preventive
care examination for new enrollees and for selected other preventive
services.[Footnote 1]
As these new benefits are implemented under MMA, you have inquired
about lessons learned from previous research on delivery options for
preventive services. Since 2002, we have done a series of reports for
Congress that examines the delivery of preventive care services to
Medicare beneficiaries. My statement today summarizes some relevant
findings from our work done before MMA, specifically:
* the extent to which Medicare beneficiaries receive preventive
services through physician visits, and:
* some of the expected benefits and limitations of delivering services
through a one-time preventive care examination, including discussion of
another delivery option being explored by the Centers for Medicare &
Medicaid Services (CMS).
My testimony today is based on reports and testimony we have issued
since 2002.[Footnote 2] Our work for these products included a
synthesis of information on preventive care received by people age 65
or older[Footnote 3] from four nationally representative health
surveys;[Footnote 4] a review of the results of past related research
demonstrations and congressionally mandated studies; and interviews
with Department of Health and Human Services (HHS) and CMS officials
and other experts. This work allows us to discuss the benefits and
limitations of the delivery of preventive services through a one-time
examination. This body of work was conducted from August 2001 through
August 2003 in accordance with generally accepted government auditing
standards. In July 2004, we updated information on recommended
preventive services and on the status of a CMS effort to explore
another delivery option.
In summary, although they typically visit a physician several times
during a year, most Medicare beneficiaries receive some but not all
recommended preventive services. Our analysis of year 2000 data shows
that nearly 9 in 10 Medicare beneficiaries visited a physician at least
once that year, and beneficiaries made an average of six visits or more
within the year. Despite these opportunities, many beneficiaries did
not receive recommended preventive services. In 2000, for example,
about 30 percent of Medicare beneficiaries did not receive an influenza
vaccination, and 37 percent had never had a pneumonia vaccination as
recommended under current guidelines for people age 65 or older.
Moreover, many Medicare beneficiaries are apparently unaware that they
may have conditions that preventive services are meant to detect. For
example, in one 1999-2000 nationally representative survey during which
people received physical examinations, nearly one-third of people age
65 or older whom the survey found to have high cholesterol measurements
said they had not previously been told by a physician or other health
professional that they had high cholesterol. Projected nationally, this
percentage translates into 2.1 million people age 65 or older who may
have had high cholesterol without knowing it.
A one-time preventive care examination may provide an opportunity for
beneficiaries to receive some preventive services while orienting new
beneficiaries to Medicare. But covering an initial examination does not
ensure that beneficiaries receive the recommended preventive services
they need. The results of a CMS demonstration conducted in the late
1980s and early 1990s indicated that offering Medicare beneficiaries
packages of broad-based preventive services slightly improved the use
of some services, such as immunizations and cancer screenings, but did
not consistently improve health or lower costs. CMS is exploring an
alternative for Medicare preventive care that, by means other than a
physician's examination, would provide systematic health risk
assessments to Medicare beneficiaries. A key component of this
demonstration, which is still in development, is to address concerns
that to be effective, risk assessments must be coupled with follow-up
interventions, such as referrals for follow-up care.
Background:
Preventive health care can extend lives and promote well-being among
our nation's seniors. Medicare now covers a number of preventive
services, including immunizations, such as hepatitis B and influenza,
and cancer screenings, such as Pap smears and colonoscopies. Not all
beneficiaries, however, avail themselves of covered preventive
services. Some beneficiaries may simply choose not to use these
services, but others may be unaware that the services are available or
covered by Medicare. Further, for some beneficiaries, certain services
may not be warranted or may be of limited value. Appropriate preventive
care depends on an individual's age and particular health risks, not
simply on the results of a standard battery of tests.
To evaluate preventive care for different age and risk groups, HHS in
1984 established the U.S. Preventive Services Task Force, a panel of
private-sector experts. The task force recommends certain screening,
immunization, and counseling services for people age 65 or older.
Medicare covers some, but not all, of these services (see table 1).
Table 1: Preventive Services Recommended by the U.S. Preventive
Services Task Force or Covered by Medicare as of August 2003:
Service: Immunization: Pneumococcal;
Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: 1981;
Medicare cost-sharing requirements[A]: None.
Service: Immunization: Hepatitis B;
Task force recommendation for age 65+: No recommendation;
Year first covered by Medicare as preventive service: 1984;
Medicare cost-sharing requirements[A]: Copayment after deductible.
Service: Immunization: Influenza;
Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: 1993;
Medicare cost-sharing requirements[A]: None.
Service: Immunization: Tetanus-diphtheria (Td) boosters;
Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: Not covered[B];
Medicare cost-sharing requirements[A]: N/A.
Service: Immunization: Varicella;
Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: Not covered[B];
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Cervical cancer: Pap smear;
Task force recommendation for age 65+: Recommends against[C];
Year first covered by Medicare as preventive service: 1990;
Medicare cost-sharing requirements[A]: Copayment with no deductible[D].
Service: Screening: Breast cancer: mammography;
Task force recommendation for age 65+: Recommends[E];
Year first covered by Medicare as preventive service: 1991;
Medicare cost-sharing requirements[A]: Copayment with no deductible.
Service: Screening: Vaginal cancer: pelvic exam;
Task force recommendation for age 65+: Not evaluated;
Year first covered by Medicare as preventive service: 1998;
Medicare cost-sharing requirements[A]: Copayment with no deductible[D].
Service: Screening: Colorectal cancer: fecal-occult blood test[F];
Task force recommendation for age 65+: Strongly recommends;
Year first covered by Medicare as preventive service: 1998;
Medicare cost-sharing requirements[A]: No copayment or deductible.
Service: Screening: Colorectal cancer: flexible sigmoidoscopy or
colonoscopy[F];
Task force recommendation for age 65+: Strongly recommends;
Year first covered by Medicare as preventive service: 1998;
Medicare cost-sharing requirements[A]: Copayment after deductible[G].
Service: Screening: Osteoporosis: bone mass measurement;
Task force recommendation for age 65+: Recommends (women only);
Year first covered by Medicare as preventive service: 1998;
Medicare cost-sharing requirements[A]: Copayment after deductible.
Service: Screening: Prostate cancer: prostate-specific antigen test and
/or digital rectal examination;
Task force recommendation for age 65+: Insufficient evidence to
recommend for or against;
Year first covered by Medicare as preventive service: 2000;
Medicare cost-sharing requirements[A]: Copayment after deductible[D].
Service: Screening: Glaucoma;
Task force recommendation for age 65+: Insufficient evidence to
recommend for or against;
Year first covered by Medicare as preventive service: 2002;
Medicare cost-sharing requirements[A]: Copayment after deductible.
Service: Screening: Vision impairment;
Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Hearing impairment;
Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Height, weight, and blood pressure;
Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Cholesterol measurement;
Task force recommendation for age 65+: Strongly recommends;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Problem drinking;
Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Screening: Depression;
Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Counseling: Smoking cessation, injury prevention, dental
health;
Task force recommendation for age 65+: Recommends;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost-sharing requirements[A]: N/A.
Service: Counseling: Aspirin for primary prevention of cardiovascular
events;
Task force recommendation for age 65+: Strongly recommends;
Year first covered by Medicare as preventive service: Not covered;
Medicare cost- sharing requirements[A]: N/A.
Source: U.S. GAO-03-958 and U.S. Preventive Services Task Force, Guide
to Clinical Preventive Services, 2nd ed. (Washington, D.C.: 1996) and
related updates. According to a task force official, since our 2003
report was issued, the task force has also recommended diabetes
screening for people age 65 or older at risk of this disease.
[A] Applicable Medicare cost-sharing requirements generally include a
20 percent copayment after a $100 per year deductible. Specifically,
each year, beneficiaries are responsible for 100 percent of the payment
amount until those payments equal a specified deductible amount, $100
in 2003. Thereafter, beneficiaries are responsible for a copayment that
is usually 20 percent of the Medicare-approved amount. For certain
tests, the copayment may be higher. 42 U.S.C. § 1395(a)(1) (2000).
[B] Although the tetanus-diphtheria (Td) and varicella (chickenpox)
booster vaccinations are not covered under Medicare as "preventive"
services, these treatments might be covered under Medicare if necessary
to a beneficiary's medical treatment. Medicare provides coverage for
medical treatment and services that are "reasonable and necessary for
the diagnosis or treatment of an illness or injury," provided that the
services or products used are "safe and effective" and not merely
"experimental." 42 U.S.C. § 1395(a)(1)(A) (2000).
[C] The task force recommends against routinely screening women older
than 65 for cervical cancer if they have had adequate recent screening
with normal Pap smears and are not otherwise at high risk for cervical
cancer.
[D] The costs of the laboratory test portion of these services are not
subject to a copayment or deductible. The beneficiary is subject to a
deductible, copayment, or both for physician services only.
[E] The task force recommends screening mammography, with or without a
clinical breast examination, every 1-2 years for women age 40 and
older.
[F] Data are insufficient to determine which strategy is best to
balance benefits against potential harm or cost-effectiveness. Barium
enemas are covered as an alternative if a physician determines that
their screening value is equal to or greater than sigmoidoscopy or
colonoscopy.
[G] The copayment has increased from 20 to 25 percent for services
provided in an ambulatory surgical center.
[End of table]
Medicare's fee-for-service program[Footnote 5] does not cover regular
periodic examinations, where clinicians might assess an individual's
health risk and provide needed preventive services. Beneficiaries could
and still can, however, receive some of these services during office
visits for other health issues.
In late 2003, MMA added coverage under Medicare for a one-time "initial
preventive physician evaluation" if performed within 6 months after an
individual's enrollment under Part B of the program.[Footnote 6]
Covered services under the examination include measurement of height,
weight, and blood pressure; an electrocardiogram; and education,
counseling, and referral services for screenings and other preventive
services covered by Medicare. MMA also added coverage for various
screening tests to identify cardiovascular disease (and related
abnormalities) in "elevated risk" beneficiaries and diabetes in "at
risk" beneficiaries.[Footnote 7] The new coverage applies to services
provided on or after January 1, 2005.
Most Beneficiaries Receive Some but Not All Recommended Preventive
Services:
Nationally representative survey data show that Medicare beneficiaries
visit physicians often and that most report receiving "routine
checkups." These data do not show, however, which specific services
were delivered during those "checkups." Despite the frequency of
visits, many Medicare beneficiaries do not receive the full range of
recommended preventive services. Data also show that many beneficiaries
may not know about their risk for health conditions that preventive
care is meant to detect.
From 2000 survey data and U. S. Bureau of the Census estimates of
people age 65 or older, we estimated that beneficiaries visited a
physician at least six times that year, on average, mainly for
illnesses or medical conditions. Only about 1 in 10 visits occurred
when beneficiaries were well (see fig. 1).[Footnote 8]
Figure 1: Major Reasons for Physician Visits by Medicare Beneficiaries
in the Fee-for-Service Program, 2000:
[See PDF for image]
Note: Numbers do not add to 100 percent because of rounding. The survey
defined an "acute problem" as a condition or illness of sudden or
recent onset, a "chronic problem" as a preexisting long-term or
recurring condition or illness, and "nonillness care" as a general
health maintenance examination or routine periodic examination of a
presumably healthy person. For chronic problems, the survey reported
results separately for "routine chronic problems" and for "chronic
problem flare-ups." We combined these results in this figure.
[End of figure]
Even though the majority of visits to physicians were to treat illness
or health conditions, most Medicare beneficiaries reported receiving
what they considered to be "routine checkups." In CDC's 2000 Behavioral
Risk Factor Surveillance System Survey, for example, 93 percent of
respondents age 65 or older reported that they had received a "routine
checkup" within the previous 2 years.[Footnote 9] This survey did not,
however, provide information on which specific services were delivered
during those checkups. Data from another survey, enumerating services
provided during office visits, indicated that Medicare beneficiaries do
receive some preventive services during visits when they are ill or
being treated for a health condition.
Despite how often Medicare beneficiaries visit physicians, relatively
few beneficiaries receive the full range of recommended preventive
services covered by Medicare. As we reported in 2002, for example,
although 91 percent of female Medicare beneficiaries in our analysis
received at least one preventive service, only 10 percent were screened
for cervical, breast, and colon cancer and were also immunized against
influenza and pneumonia.[Footnote 10] Our analysis of additional data
for our 2003 report showed that many Medicare beneficiaries still did
not receive certain recommended preventive services. The task force
recommends, for example, that all people age 65 or older receive an
annual influenza vaccination and at least one pneumonia vaccination.
According to data from CMS's Medicare Current Beneficiary Survey of
2000, however, about 30 percent of Medicare beneficiaries did not
receive an influenza vaccination, and 37 percent had never had a
pneumonia vaccination.
Many Medicare beneficiaries may not know that they are at risk for
health conditions that preventive care could detect--strong evidence
that they may not be receiving the full range of recommended preventive
services.[Footnote 11] For example, data from CDC's NHANES for 1999-
2000 show that, of beneficiaries participating in this nationally
representative survey who, as part of the survey, had a physical
examination and were found to have elevated blood pressure readings at
that time, 32 percent reported that no physician or other health
professional had told them about the condition before. On the basis of
this survey, we estimate that, during the period when the survey was
conducted, 21 million Medicare beneficiaries may have been at risk for
high blood pressure, and an estimated 6.6 million of them may have been
unaware of this risk. Similarly, 32 percent of those found by the
survey to have a high cholesterol level reported that no one had told
them that they had high cholesterol. Projected nationally, this
percentage translates into 2.1 million Medicare beneficiaries who may
have had high cholesterol without knowing it (see fig. 2).
Figure 2: Estimated Number of Medicare Beneficiaries Age 65 or Older
Who Were Aware or Unaware That They Might Have High Blood Pressure or
High Cholesterol, 1999-2000:
[See PDF for image]
Note: CDC's NHANES measured blood pressure three or four times during
its 1-day physical examination. For our analysis, we calculated the
average of the blood pressure measurements and applied CDC's definition
of high blood pressure: that is, a patient's having an average systolic
blood pressure equal to or greater than 140, or an average diastolic
blood pressure equal to or greater than 90, or a patient who reported
taking hypertension medication. CDC defined high cholesterol as a total
cholesterol level equal to or greater than 240.
[End of figure]
An Initial Examination May Improve Preventive Care, but Follow-up Is
Also Key:
A one-time initial preventive care examination covered by Medicare may
offer opportunity to deliver some preventive services but alone is not
enough to ensure better health among beneficiaries. Information from a
CMS demonstration and from other related studies shows that ensuring
receipt of follow-up care will be important to improving beneficiaries'
health. A proposed CMS demonstration, currently in design, will explore
another preventive care delivery option and examine the value of
linking beneficiaries to needed follow-up services.[Footnote 12]
As proponents of a one-time "Welcome to Medicare" examination told us,
such an examination could be a means to better ensure that health care
providers have enough time to identify individual Medicare
beneficiaries' health risks and provide preventive services appropriate
for their risks. It could be used to orient new beneficiaries to
Medicare and encourage them to make informed choices about providers
and plans. Nevertheless, a one-time examination does not ensure
delivery of the full range of preventive services. Primary care
physicians typically cannot provide services such as mammography
screenings for breast cancer or colonoscopies for colon cancer, because
these services usually require specialists.
It also is uncertain whether a one-time or periodic examination would
be an effective way to improve beneficiaries' health. For example, one
previous CMS initiative that included preventive health care visits
ended with mixed results. In the late 1980s and early 1990s, the agency
conducted a congressionally mandated demonstration to test varied
health promotion and disease prevention services, such as free
preventive visits, health risk assessment, and behavior counseling, to
see if they would increase use of preventive services, improve health,
or lower health care expenditures for Medicare beneficiaries.[Footnote
13] The agency's final report, published in 1998, concluded that the
demonstration services were marginally effective in raising the use of
some simple disease-prevention measures, such as immunizations and
cancer screenings, but did not consistently improve beneficiary health
or reduce the use of hospital or skilled nursing services.[Footnote 14]
The report tempered these results by pointing out that the relatively
brief period during which the services were provided (roughly 2 years)
and the limited number of follow-ups and beneficiary contacts with
providers (one to two) may have been inadequate to achieve measurable
outcomes.
Determining how to better ensure adequate follow-up once health risks
are identified is a concern that a new CMS project aims to evaluate.
CMS is exploring an alternative for Medicare preventive care that would
provide systematic health risk assessments to fee-for-service
beneficiaries through a means other than examination by a physician. In
the late 1990s, the agency commissioned the RAND Corporation to
evaluate the potential effectiveness of health risk assessment
programs. Such programs collect information from individuals; identify
their risk factors; and refer the individuals to at least one
intervention to promote health, sustain function, or prevent
disease.[Footnote 15] The study concluded that health risk assessment
programs have increased beneficial behavior (particularly exercise) and
improved physiological variables (particularly diastolic blood
pressure and weight) and general health.[Footnote 16] In addition, the
study stated that to be effective, risk assessment questionnaires must
be coupled with follow-up interventions, such as referrals to
appropriate services. The study recommended that CMS conduct a
demonstration to test cost-effectiveness and other aspects of the
health risk assessment approach for Medicare beneficiaries.
Following through on the study's findings, CMS has begun designing a
demonstration project focused on Medicare fee-for-service
beneficiaries, called the Medicare Senior Risk Reduction Program, to
identify health risks and follow up with preventive services provided
by means other than examinations by physicians. The program will use a
beneficiary-focused health risk assessment questionnaire to assess
health risks, such as lifestyle behaviors, and use of clinical
preventive and screening services. The program will test different
approaches to administering health risk assessments, creating feedback
reports, and providing follow-up services, such as referring
beneficiaries to health-promoting community services including
physical activity and social support groups. According to project
researchers, the program will tailor preventive interventions to
individual risks; track patient risks and health over time; and provide
beneficiaries with self-management tools and information, health
behavior advice, and end-of-life counseling where appropriate. The
design phase had not been finalized as of last week and, according to a
CMS official, still required approval from HHS and the Office of
Management and Budget.[Footnote 17]
Concluding Observations:
Current data indicate that many opportunities exist for Medicare
beneficiaries to receive preventive care, but many beneficiaries
nonetheless fail to receive the full range of recommended services.
Although some beneficiaries may not choose to seek these services,
others may not be aware that these services are available and covered
by Medicare. Our work shows that more needs to be done to deliver
preventive services to those beneficiaries who need them, because many
people may have a health condition that preventive services can easily
diagnose, and yet they may not know that they have this condition.
A one-time preventive care examination will add a dedicated opportunity
for delivering preventive care and could help reduce the gap in the
preventive services that Medicare beneficiaries receive. At the same
time, it is not a panacea. Ensuring that beneficiaries receive needed
services and follow-up care is likely to remain a challenge.
Mr. Chairman, this concludes my prepared statement. I will be happy to
answer any questions that you or Members of this Committee may have.
Contact and Acknowledgments:
For future contacts regarding this testimony, please call Janet
Heinrich at (202) 512-7119. Katherine Iritani, Matt Byer, Ellen W. Chu,
Lisa Lusk, and Behn Miller Kelly also made key contributions to this
testimony.
FOOTNOTES
[1] Pub. L. No. 108-173, 117 Stat. 2066.
[2] See U.S. General Accounting Office, Medicare: Beneficiary Use of
Clinical Preventive Services, GAO-02-422 (Washington, D.C.: April
2002); Medicare: Use of Preventive Services Is Growing but Varies
Widely, GAO-02-777T (Washington, D.C.: May 23, 2002); and Medicare:
Most Beneficiaries Receive Some but Not All Recommended Preventive
Services, GAO-03-958 (Washington, D.C.: September 2003).
[3] We focused this work on the people covered by Medicare who are 65
or older--about 86 percent of the entire Medicare population. Besides
this age group, Medicare also covered about 5.8 million disabled
persons younger than age 65, whom our work did not include. Throughout
this testimony, except where otherwise noted, we use the term "Medicare
beneficiaries" to refer only to those beneficiaries age 65 or older.
[4] The Centers for Disease Control and Prevention's (CDC) Behavioral
Risk Factor Surveillance System asks a range of health questions over
the telephone, including if respondents received a "routine checkup"
within the past year. CMS's Medicare Current Beneficiary Survey
collects self-reported data, including whether respondents have
received influenza or pneumonia immunizations. CDC's National Health
and Nutrition Examination Survey (NHANES) collects data on health
conditions by means of both comprehensive health examinations and
interviews, where patients self-report information, including whether a
physician or other health professional has ever told them that they
have a given health condition. Unlike the other surveys, which take a
sample of the population, CDC's National Ambulatory Medical Care Survey
samples physician practices, collecting detailed information about
office visits, including the major reason for the visit and which
preventive services were ordered or provided.
[5] "Fee-for-service" is the Medicare arrangement sometimes referred to
as the original Medicare plan. Under this option, Medicare pays a
health care practitioner for each visit or procedure received by a
patient, and a beneficiary can visit any hospital, physician, or health
care provider who accepts Medicare patients. Medicare pays a set
percentage of the expenses, and the beneficiary is responsible for
certain deductibles and coinsurance payments--the portion of the bill
that Medicare does not pay. Our September 2003 report indicated that
about 84 percent of Medicare enrollees were in the fee-for-service
program.
[6] The Medicare Program is divided into three parts. Part A provides
hospital insurance coverage, and Part B provides coverage for
supplemental medical insurance benefits, such as the preventive health
care services discussed above. Part C requires managed care plans
participating in the Medicare + Choice program to provide all the basic
benefits covered under Parts A and B.
[7] The new preventive care services requirements appear at Pub. L. No.
108-27, §§ 611-613, 117 Stat. 2303-2306 (adding sections 1861(s)(2)(W),
(X), and (Y) to SSA) (to be codified at 42 U.S.C. §§ 1395x(s)(2)(W),
(X), and (Y).)
[8] Because Medicare's fee-for-service program covers some preventive
services, such as immunizations and certain cancer screening tests, it
is possible that some of the nonillness visits in 2000 were to obtain
such services. In addition, some fee-for-service beneficiaries may be
paying for nonillness examinations through other means, such as
employer-provided or other supplemental insurance. According to CMS's
Medicare Current Beneficiary Survey, in the year 2000 about 41 percent
of Medicare fee-for-service beneficiaries had insurance from former
employers to supplement their basic Medicare benefit.
[9] In 2000, data from CMS's Medicare Current Beneficiary Survey also
showed that 88 percent of Medicare beneficiaries reported that they
visited a physician at least once that year.
[10] In January 2003, the U.S. Preventive Services Task Force released
new recommendations for the use of Pap smears to screen for cervical
cancer. The task force now "recommends against screening women 65 or
older who have had adequate recent screenings with normal Pap smears
and are not otherwise at increased risk for cervical cancer."
[11] The source of data for this statement was CDC's NHANES of 1999-
2000. This survey oversampled; that is, it included a larger number of
persons age 60 and older in the sample, providing for a sample size
that enabled us to focus our analysis specifically on the Medicare-age
population for selected conditions.
[12] We confirmed in July 2004 that this CMS demonstration was still in
the design phase.
[13] The Consolidated Omnibus Budget Reconciliation Act of 1985
directed CMS (then known as the Health Care Financing Administration)
to conduct a 4-year demonstration (see Pub. L. No. 99-272, § 9314, 100
Stat. 82, 194-196 (1986)), which was extended for an additional year by
the Omnibus Budget Reconciliation Act of 1990, Pub. L. No. 101-508, §
4164, 104 Stat. 1388, 1388-100.
[14] Donna E. Shalala, Medicare Prevention Demonstration: Final Report,
RC 87-172 (Washington, D.C.: Department of Health and Human Services,
1998).
[15] A typical health risk assessment obtains information on
demographic characteristics (e.g., sex, age); lifestyle (e.g., smoking,
exercise, alcohol consumption, diet); personal health history; and
family health history. In some cases, physiological data (e.g., height,
weight, blood pressure, cholesterol levels) are also obtained, as well
as a patient's status regarding cancer screens and immunizations.
[16] Southern California Evidence-Based Practice Center/RAND, Health
Risk Appraisals and Medicare (Baltimore: Centers for Medicare &
Medicaid Services, 2001). RAND identified 267 articles, unpublished
reports, and conference presentations, of which 27 contained data that
project staff deemed necessary to be included as evidence of the
effectiveness of health risk assessments.
[17] The demonstration's final cost was uncertain at the time our
report was completed in September 2003. CMS was spending approximately
$1 million on the developmental work.